€.T  CufoSX?) 


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Reprinted  from  the  Transactions  of  the  Eighth  Annual  Meeting  of 
The  National  Association  for  the  Study  and  Prevention  of  Tuberculosis 


ADVANCED  TUBERCULOSIS  CONEINED  TO  ONE 
LUNG ;  A  COMPARATIVE  ANALYSIS  OF  150  CASES 

By  F.  C.  Smith,  M.D. 

Fort  Stanton,  N.  M. 


The  present  study  comprises  1705  moderately  advanced  and  far-advanced 
cases,  so  classified  on  admission  to  the  Marine-Hospital  Sanatorium,  and 
particularly  150  of  those  in  which  no  sign  of  disease  was  detected  in  one 
lung,  either  at  the  first  examination  or  at  the  second,  two  months  later. 

In  95  of  these  the  right  lung  was  involved,  in  55  the  left.  It  is  possible 
that  the  opposite  apex  had  been  previously  involved,  the  left  seven  times 
and  the  right  eleven,  as  slight  variations  from  normal,  but  no  signs  of  active 
disease  w^re  detected  in  these  instances. 

TABULATION  OF  CASES  OF  ADVANCED  DISEASE  CONFINED  TO  ONE 

LUNG  ON  ADMISSION 

U.  S.  Marine-Hospital  Sanatorium 
Moderately  Advanced 


Apparently 

Cured 

Arrested 

Improved 

Unimproved 

Dead 

Whole  number,  693  .... 

III 

119 

302 

66 

95 

Confined  to  one  lung,  87 

26 

22 

21 

13 

5* 

Right  lung  involved,  59  . 

18 

19 

12 

7 

3 

Left  lung  involved,  28 .  .  . 

8 

3 

9 

6 

2 

Far -Advanced 


Apparently 

Cured 

Arrested 

Improved 

Unimproved 

Dead 

Whole  number,  1012  .  .  . 

26 

125 

234 

IIS 

512 

Confined  to  one  lung,  63 

5 

20 

12 

7 

19* 

Right  lung  involved,  36. 

3 

12 

7 

5 

9 

Left  lung  involved,  27  .  . 

2 

8 

5 

2 

10 

*  Two  of  the  24  cases  were  not  autopsied. 


2 


ADVANCED  TUBERCULOSIS  CONFINED  TO  ONE  LUNG 


Advanced  one-sided  disease  is  thus  seen  to  be  nearly  twice  as  frequent  on 
the  right  side  as  on  the  left,  which  supports  in  a  measure  the  idea  that  the 
right  side  is  most  frequently  attacked.  The  comparatively  small  number 
of  cases,  however,  would  indicate  that  disease  past  incipiency  is  not  long 
confined  to  one  lung. 

While  under  treatment  the  sound  left  lung  became  involved  22  times 
out  of  95,  and  the  sound  right  lung  15  times  out  of  55,  the  disease  showing 
very  little  difference  in  its  relative  tendency  to  extend  from  one  lung  to 
the  other.  This  fresh  involvement  of  the  sound  lung  was  evanescent^ 
subacute,  and  never  serious  in  19,  and  was  not  detected  before  autopsy  in 
5,  while  in  12  instances  an  acute  involvement  of  the  sound  lung  was  serious 
enough  to  have  caused  death  soon,  although  3  of  these  patients  died  of 
hemorrhage.  Of  the  12  last  mentioned,  7  were  right-sided  cases  which  ex¬ 
tended  to  the  left  lung,  and  5  were  cases  of  left-sided  disease  extending  to 
the  right.  Only  one  normal  lung  was  found  in  the  22  autopsies  in  this 
series,  i.  e.,  the  right  lung  in  the  patient  dying  from  ruptured  aortic  aneurysm. 

When  the  better  lung  became  involved,  the  apex  was  the  part  usually 
first  affected,  but  the  antero-external  portion  of  the  base  of  the  left  upper 
lobe  was  attacked  twice  and  the  antero-external  border  of  the  left  lower 
lobe  once,  the  latter  being  found  only  at  autopsy,  a  very  small  patch  of 
subpleural  infiltration. 

Comparing  the  results  in  advanced  one-sided  cases  with  advanced  dis¬ 
ease  in  both  lungs,  the  one-sided  cases  show,  as  might  be  expected,  a  much 
higher  percentage  of  recoveries.  Thus,  while  the  one-sided  cases  furnish 
only  8.8  per  cent,  of  the  whole  number,  they  show  22.6  per  cent,  of  the  appar¬ 
ent  cures,  17  per  cent,  of  the  arrests,  and  only  4  per  cent,  of  the  deaths. 

There  were  24  deaths  in  this  series:  i  caused  by  ruptured  aortic  aneurysm, 
I  by  tabes  dorsalis  and  tuberculosis  of  the  kidneys,  i  by  pneumothorax, 
I  by  tuberculosis  of  the  larynx,  i  by  empyema,  i  by  nephritic  coma,  i  by 
hemorrhage  from  the  bowel,  7  by  hemorrhage  from  the  lung,  2  by  acute 
invasion  of  the  better  lung  following  hemorrhage,  4  by  acute  invasion  of  the 
better  lung  without  known  cause,  and  the  remaining  4  by  sepsis,  invasion 
of  the  better  lung,  and  advanced  terminal  changes.  An  unusually  large 
number  of  deaths  in  this  series  was  due  to  accident  or  complication  pecu¬ 
liar  to  tuberculosis.  I  believe  that  advanced  cases  with  disease  confined 
to  one  lung  enjoy  a  greater  degree  of  chronicity  than  the  usual  type  of 
advanced  case,  and  that  chronicity  affords  greater  opportunity  for  accident 
or  complication.  This  has  been  previously  investigated  with  regard  to  death 


4'^, 5-^2 

6  CL 


F.  C.  SMITH,  M.D.  3 

from  hemorrhage  at  the  Fort  Stanton  Sanatorium.*  It  should  be  noted  that 
we  have  had  71  deaths  from  hemorrhage  out  of  a  total  of  658  fatalities 
at  this  station,  a  mortality  of  10.8  per  cent,  from  hemoptysis.  In  this 
series,  however,  of  24  deaths  7,  or  over  29  per  cent.,  were  due  to  hemor¬ 
rhage  from  the  lungs. 

Comparing  the  results  of  treatment  of  the  cases  of  right-sided  involve¬ 
ment  with  those  of  left-sided,  there  is  no  great  difference.  Reduced  to 
percentages  and  tabulated  it  is  seen  that  the  cases  of  right  lung  involvement 
show  slightly  better  results. 

COMPARISON  OF  RESULTS  OF  TREATMENT;  RIGHT-SIDED  AND  LEFT¬ 
SIDED  INVOLVEMENT 


Moderately  advanced  Far -advanced 


Right  Lung 
Involved 

Left  Lung 
Involved 

Right  Lung 
Involved 

Left  Lung 
Involved 

Apparently  cured . 

31  per  cent. 

28.5  per  cent. 

8  per  cent. 

7  per  cent. 

Arrested  . 

32  per  cent. 

II  per  cent. 

33  per  cent. 

30  per  cent. 

Improved . 

20  per  cent. 

32  per  cent. 

20  per  cent. 

19  per  cent. 

Unimproved  and  dead . 

17  per  cent. 

28.5  per  cent. 

39  per  cent. 

44  per  cent. 

Symptoms. — Dyspnea  and  pulse-rate  were  compared  in  this  series,  with 
the  following  results:  Seventeen  per  cent,  of  cases  with  right  lung  involve¬ 
ment  suffered  considerable  dyspnea,  12  per  cent,  of  cases  with  left  lung 
involvement  were  so  affected.  Sixty-one  per  cent,  of  right  lung  involve¬ 
ment  had  an  average  pulse-rate  above  84,  69  per  cent,  of  left  lung  involve¬ 
ment  showed  pulse-rate  above  this  number.  There  would  seem  to  be  no 
great  difference  in  the  amount  of  respiratory  or  circulatory  embarrassment 
caused  by  involvement  of  either  lung. 

As  a  matter  of  casual  interest  I  investigated  all  the  phenomenal  recov¬ 
eries  from  very  far-advanced  disease  at  the  Fort  Stanton  Sanatorium. 
By  this  is  meant  those  cases  where  patients  with  complete  involvement 
of  at  least  one  lung  and  extensive  excavation  have  sufficiently  recovered 
to  work  and  otherwise  lead  an  active  life  for  several  years.  The  average 
stay  of  these  individuals  at  the  Sanatorium  was  a  little  over  three  years,  all 
being  employed  as  attendants  at  different  times.  There  have  been  19  such 

*  “Pulmonary  Hemorrhage  in  the  Tuberculous  at  High  Altitude,”  Public  Health 
Reports,  vol.  xxv.  No.  4,  October  17,  1910. 


4 


ADVANCED  TUBERCULOSIS  CONFINED  TO  ONE  LUNG 

phenomenal  cases,  ii  being  instances  where  the  right  lung  was  the  one 
chiefly  involved,  and  8  where  the  left  was  more  affected. 


SUMMARY 

1.  Advanced  pulmonary  tuberculosis  is  not  often  (8.8  per  cent,  in  this 
series)  confined  to  one  lung. 

2.  In  advanced  disease  confined  to  one  lung  the  right  is  affected  most 
frequently. 

3.  Extension  of  disease  from  either  lung  to  the  opposite  seems  about 
equally  frequent,  and  serious  in  about  the  same  proportion. 

4-  The  sound  lung  when  freshly  involved  seemed  to  show'  a  fair  degree 
of  resistance.  The  apex  was  usually  first  affected. 

5.  The  prognosis  in  advanced  disease  confined  to  one  lung  is  more 
favorable  than  wTen  both  are  actively  affected. 

6.  Deaths  from  accident  (hemorrhage)  or  complications  w'ere  unusually 
frequent;  unusual  chronicity  is  suggested  as  a  possible  explanation. 

7.  Cases  w'here  the  right  lung  only  w’as  involved  show'ed  slightly  better 
results  than  w'here  the  left  onl}^  w'as  affected. 

8.  Dyspnea  and  rapid  pulse  w'ere  experienced  in  about  the  same  degree, 
d}-spnea  being  slightly  more  noticeable  in  the  cases  of  right-lung  involve¬ 
ment  and  tachycardia  in  left-sided  disease. 

9.  Of  19  recoveries  from  very  far-advanced  disease  with  restoration  to 
working  capacity,  ii  were  cases  of  right-lung  involvement  and  8  of  left. 


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